Mongolian HDIT Implementation guide
1.0.0 - Review

Mongolian HDIT Implementation guide - Local Development build (v1.0.0). See the Directory of published versions

StructureDefinition: PhysicalExamNote

Physical examination note

The official URL for this profile is: 

http://fhir.mn/StructureDefinition/mng-observation-physical-examination

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ObservationMn

Summary

Mandatory: 2 elements
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.effective[x] is sliced based on the value of type:$this
  • The element Observation.component is sliced based on the value of pattern:code

This structure is derived from ObservationMn

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMnMeasurements and simple assertions
... code 1..1CodeableConceptType of observation (code / type)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8713-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Physical findings of General status
... subject 1..1Reference(PatientMn)Who and/or what the observation is about
... effective[x] 1..1(Slice Definition)Clinically relevant time/time-period for observation
Slice: Unordered, Open by type:$this
... value[x] 0..1stringActual result
... component 0..*(Slice Definition)Component results
Slice: Unordered, Open by pattern:code
.... component:advice S0..1BackboneElementComponent results
..... code S1..1CodeableConceptType of component observation (code / type)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 84635008
....... display1..1stringRepresentation defined by the system
Fixed Value: Disease process or condition education (procedure)
..... value[x] 0..1stringActual component result

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationMnMeasurements and simple assertions
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..*IdentifierBusiness Identifier for observation
... basedOn ΣI0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf ΣI0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!ΣI1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category I0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)
... code ΣI1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8713-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Physical findings of General status
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject SΣI1..1Reference(PatientMn)Who and/or what the observation is about
... focus ΣI0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter ΣI0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] ΣI1..1(Slice Definition)Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime SΣI1..1dateTimeClinically relevant time/time-period for observation
... issued ΣI0..1instantDate/Time this version was made available
... performer ΣI0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣI0..1stringActual result
... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... note I0..*AnnotationComments about the observation
... bodySite I0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example)
... method I0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... referenceRange I0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type I0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... text I0..1stringText based reference range in an observation
... hasMember ΣI0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom ΣI0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component ΣI0..*(Slice Definition)Component results
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code ΣI1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
..... value[x] ΣI0..1Actual component result
...... valueQuantityQuantity
...... valueCodeableConceptCodeableConcept
...... valueStringstring
...... valueBooleanboolean
...... valueIntegerinteger
...... valueRangeRange
...... valueRatioRatio
...... valueSampledDataSampledData
...... valueTimetime
...... valueDateTimedateTime
...... valuePeriodPeriod
..... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
..... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
..... referenceRange I0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
.... component:advice SΣI0..1BackboneElementComponent results
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code SΣI1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 84635008
....... display1..1stringRepresentation defined by the system
Fixed Value: Disease process or condition education (procedure)
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value[x] ΣI0..1stringActual component result
..... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
..... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
..... referenceRange I0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format

This structure is derived from ObservationMn

Summary

Mandatory: 2 elements
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Observation.effective[x] is sliced based on the value of type:$this
  • The element Observation.component is sliced based on the value of pattern:code

Differential View

This structure is derived from ObservationMn

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMnMeasurements and simple assertions
... code 1..1CodeableConceptType of observation (code / type)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8713-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Physical findings of General status
... subject 1..1Reference(PatientMn)Who and/or what the observation is about
... effective[x] 1..1(Slice Definition)Clinically relevant time/time-period for observation
Slice: Unordered, Open by type:$this
... value[x] 0..1stringActual result
... component 0..*(Slice Definition)Component results
Slice: Unordered, Open by pattern:code
.... component:advice S0..1BackboneElementComponent results
..... code S1..1CodeableConceptType of component observation (code / type)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 84635008
....... display1..1stringRepresentation defined by the system
Fixed Value: Disease process or condition education (procedure)
..... value[x] 0..1stringActual component result

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationMnMeasurements and simple assertions
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..*IdentifierBusiness Identifier for observation
... basedOn ΣI0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf ΣI0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!ΣI1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category I0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)
... code ΣI1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 8713-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Physical findings of General status
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... subject SΣI1..1Reference(PatientMn)Who and/or what the observation is about
... focus ΣI0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter ΣI0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] ΣI1..1(Slice Definition)Clinically relevant time/time-period for observation
Slice: Unordered, Closed by type:$this
.... effective[x]:effectiveDateTime SΣI1..1dateTimeClinically relevant time/time-period for observation
... issued ΣI0..1instantDate/Time this version was made available
... performer ΣI0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)Who is responsible for the observation
... value[x] ΣI0..1stringActual result
... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... note I0..*AnnotationComments about the observation
... bodySite I0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example)
... method I0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... referenceRange I0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type I0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... text I0..1stringText based reference range in an observation
... hasMember ΣI0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom ΣI0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component ΣI0..*(Slice Definition)Component results
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code ΣI1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
..... value[x] ΣI0..1Actual component result
...... valueQuantityQuantity
...... valueCodeableConceptCodeableConcept
...... valueStringstring
...... valueBooleanboolean
...... valueIntegerinteger
...... valueRangeRange
...... valueRatioRatio
...... valueSampledDataSampledData
...... valueTimetime
...... valueDateTimedateTime
...... valuePeriodPeriod
..... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
..... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
..... referenceRange I0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result
.... component:advice SΣI0..1BackboneElementComponent results
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... code SΣI1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: 84635008
....... display1..1stringRepresentation defined by the system
Fixed Value: Disease process or condition education (procedure)
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... value[x] ΣI0..1stringActual component result
..... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
..... interpretation I0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
..... referenceRange I0..*Unknown reference to #Observation.referenceRange
Provides guide for interpretation of component result

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Max Binding: AllLanguages
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.codeexamplePattern: LOINC code 8713-0("Physical findings of General status")
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.component.codeexampleLOINCCodes
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes
Observation.component:advice.codeexamplePattern: SNOMED CT code 84635008("Disease process or condition education (procedure)")
Observation.component:advice.dataAbsentReasonextensibleDataAbsentReason
Observation.component:advice.interpretationextensibleObservationInterpretationCodes

Constraints

Constraints

IdPathDetailsRequirements